Risk factors for the histologic discrepancy of gastric adenomatous lesions and long-term outcome

Although endoscopic forceps biopsies (EFB) have a significant role in diagnosing gastric adenoma, there are still discrepancies between EFBs and finalized pathology results.Therefore, the objective of this study was to find the risk factors that cause this discrepancy and to analyze the effects of this discrepancy on the long-term outcome.In this study patients that had received endoscopic resection due to low-grade gastric adenoma diagnosis from EFB between January of 2011 and January of 2018 at the Chungnam National University Hospital were retrospectively analyzed. According to whether there was histological discrepancy the cumulative incidence of the metachronous lesions were analyzed.A total of 745 lesions diagnosed as low-grade gastric adenoma at EFB were enrolled, and the final pathology results were confirmed to be non-neoplastic (n = 19), low-grade adenoma (n = 614), High-grade adenoma (n = 63), and carcinoma (n = 49), and with the exception of non-neoplastic lesion, the results confirmed 84.6% (n = 614) for the concordant group and 15.4% (n = 112) for the discordant. The results of the multivariate analysis confirmed that depressed lesion (odds ratio [OR]: 2.056; 95% confidence interval [CI]: 1.130–3.451; P = .011), erythema (OR: 2.546; 95% CI: 1.604–4.030; P = .004), and a size >1.5 cm (OR: 1.903; 95% CI: 1.102–3.172; P = .018) were risk factors for discrepancy. The results also confirmed that for the average observation period of (SD) 39.12 (12.31) months, the cumulative incidence of metachronous neoplasm had a higher significance (P = 0.001) in the discordant group when compared to that of the concordant group.The factors related to the histologic discrepancy of low-grade gastric adenoma were depressed lesion, erythema and size >1.5 cm. In the groups with histological discrepancy, the cumulative incidence of the metachronous neoplasm was significantly higher and therefore closer observation of such patients after performing endoscopic resection is necessary.     

Initial evaluation of the forward-viewing echoendoscope prototype for performing fine-needle aspiration, Tru-cut biopsy, and celiac plexus neurolysis

Background and Aims: A forward‐viewing echoendoscope (FV‐CLA) has been recently developed for performing interventional endoscopic ultrasound (EUS). The role of FV‐CLA in performing standard EUS‐guided fine‐needle aspiration (FNA), Tru‐cut biopsy (TCB), and celiac plexus neurolysis (CPN) is unknown. Our aims were to evaluate the feasibility of the FV‐CLA for performing EUS‐guided FNA/TCB and CPN. Methods: In this prospective study conducted over a 3‐month period, 30 patients were evaluated with the FV‐CLA. Procedures performed were FNA in 28 lesions, TCB in one, and CPN in five patients. Results: EUS‐guided FNA was undertaken at the following sites: mediastinum (n = 3), liver (n = 2), retroperitoneal mass (n = 2), pancreas head/uncinate (n = 9), pancreas body (n = 6), pancreas tail (n = 4), and perigastric lymph node (n = 2). The median size of the lesions was 37 × 34 mm. A median of two passes was performed (range: 1–7). Final cytopathology diagnosed malignancies in 21 patients, with adenocarcinoma suspected for one.TCB of a mediastinal lymph node revealed lymphoma. FNA was benign in six patients. The sensitivity, specificity, positive predictive value, and negative predictive value for a malignancy diagnosis was 96% (95% confidence interval [CI], 87–96%), 100% (95% CI, 70–100%), 100% (92–100), and 86% (60–86%), respectively. CPN was successful in all five patients. It was easier to deploy the needle from the echoendoscope at all locations, including the duodenum, and irrespective of the site of the lesion. Conclusions: The initial evaluation and safety profile of the FV‐CLA echoendoscope for performing standard FNA/TCB and CPN appear to be favorable. The narrow image does not preclude basic therapeutic maneuvers. A major advantage appears to be easy needle deployment at any site within reach of the echoendoscope.     

Differences in endoscopic views during biopsy through the right and left lower biopsy channels of the upper gastrointestinal endoscope

Background: It has not been established as to which side the biopsy (instrument) channel should be placed in the tip of a front‐viewing upper gastrointestinal (GI) endoscope to allow an en‐face approach to lesions on various aspects of the stomach wall. Methods: Using a front‐viewing two‐channel endoscope, we identi?ed a difference in endoscopic views during biopsy between lower‐right and lower‐left channels. Colored marks were distributed on the lesser curvature (LC), greater curvature (GC), anterior wall (AW), and posterior wall (PW) in the ‘stomach’ of a dummy for mock‐performance of upper GI endoscopy. When biopsy forceps through the different channels touched the marks, an endoscopic photograph was taken. Furthermore, when biopsy specimens were obtained from PW lesions in several patients, endoscopic views were compared between the two biopsy channels. Results: In the dummy study, no remarkable difference was detected in targeting the marks on AW, LC, or GC of the stomach. The dummy and the patient study showed that the lower‐right approach could target PW lesions with a more adequate endoscopic view than from the lower left. The lower‐left approach targeted PW lesions on the higher body with a nearly blinded endoscopic view. Specimens from PW of the upper body, which could be precisely obtained under direct visual control through the lower‐right channel, were no smaller than those obtained using the channel on the lower left. Conclusion: The present study suggests that the lower‐right channel may be preferable to the lower‐left channel in the tip of a front‐viewing upper GI endoscope.     

Comparison of 22-gauge aspiration needle with 22-gauge biopsy needle in endoscopic ultrasonography-guided subepithelial tumor sampling

Abstract

Objective. Endoscopic ultrasonography (EUS)-guided fine-needle aspiration (EUS-FNA) may facilitate tissue sampling for histopathological diagnosis of subepithelial tumors (SETs) in the gastrointestinal (GI) tract. However, immunohistochemistry is not always feasible using EUS-FNA samples due to the low quality of specimens often obtained by aspiration. This study aimed to compare the use of 22-gauge (G) EUS-guided fine-needle biopsy (EUS-FNB) with 22G EUS-FNA for core sampling used for histopathological examination, including immunohistochemistry, in patients with GI SETs. Methods. Twenty-eight patients with GI SETs ≥2 cm in size were prospectively enrolled at five university hospitals in Korea between January and June 2013. They were randomized to undergo either EUS-FNB or EUS-FNA. Results. A total of 22 patients was finally analyzed in this study: 10 and 12 patients underwent EUS-FNA and EUS-FNB, respectively. Compared to the EUS-FNA group, the EUS-FNB group had a significantly lower median number of needle passes to obtain macroscopically optimal core samples (4 vs. 2, p = 0.025); higher yield rates of macroscopically and histologically optimal core samples with three needle passes (30% vs. 92%, p = 0.006; 20% vs. 75%, p = 0.010, respectively); and a higher diagnostic sufficiency rate (20% vs. 75%, p = 0.010). No technical difficulties were encountered in either group. Conclusions. This study shows that EUS-FNB has a better ability to obtain histological core samples and a higher diagnostic sufficiency rate than EUS-FNA and that EUS-FNB is a feasible, safe, and preferable modality for adequate core sampling for histopathological diagnosis of GI SETs.     

Biliary guidewire facilitates bile duct biopsy and endoscopic drainage

BACKGROUND: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage. METHODS: Endoscopic bile duct biopsy was attempted in 61 patients with bile duct strictures. After the introduction of a guidewire into the bile duct, biopsy forceps were inserted via the papilla. Both devices were inserted through the working channel (3.2 mm in diameter) of a conventional duodenoscope. After the procedure, an endoscopic naso-biliary drainage catheter was advanced along the guidewire. The success rate of inserting the biopsy forceps, the sensitivity of the biopsy, and the success rate of endoscopic biliary drainage after the biopsy were analyzed prospectively. RESULTS: The final diagnosis was malignant strictures in 50 patients and benign strictures in 11. The success rate of inserting biopsy forceps without performing endoscopic papillary balloon dilation was 85%. The sensitivity of the biopsy for primary bile duct cancer (83%) was significantly higher (P < 0.05) than that of pancreatic cancer (47%). All patients had successful endoscopic biliary drainage after the procedure. CONCLUSION: A previously placed guidewire facilitates insertion of biopsy forceps and endoscopic biliary drainage. The histological diagnosis of cancer is more likely with bile duct cancer than with pancreatic cancer.     

Mucosectomy for gastric cancer: Current status in Japan

Advances in techniques of image diagnosis have enabled the detection of minute or small cancer lesions in the stomach. Patients with such cancer, in principle, were treated surgically, but accumulated histopathological data on surgical cancer specimens revealed that many of these patients did not have any metastatic lesions. For those localized cancers, local treatment of primary lesions by endoscopy gives curative results. It has been demonstrated that endoscopic therapy is curative in mucosal well‐differentiated adenocarcinoma not more than 20 mm in diameter without ulceration. Efforts to cure early gastric cancer without surgery yielded fruitful results and a new treatment concept was established. Even if there is a recurrence of the residual or metachronous lesions, they can be treated by further endoscopic treatment.     

Duodenal Adenoma Removed by Endoscopic Polypectomy

Abstract: We report two duodenal adenoma cases treated by endoscopic polypectomy. Case 1, a 59-year-old male, visited our hospital for further examination of a duodenal polyp found elsewhere. X-ray examination revealed a semi-pedunculated polyp with an irregular surface in the second portion of the posterior wall of the duodenum. Case 2, a 68-year-old male, was admitted to our hospital for endoscopic polypectomy of a duodenal polyp. Upper GI series demonstrated a semi-pedunculated round polyp with a shallow central depression. Endoscopic polypectomy was performed for both lesions and the polyps were successfully removed. The resected polyps were 11 × 10 mm and 13 × 12 mm in size, respectively. The polyps were histologically diagnosed as tubulovillous and tubular adenomas, respectively, with no evidence of malignancy. Endoscopic polypectomy provides histological confirmation of adenoma of the gastrointestinal tract, and it is frequently applicable to the duodenum.     

Induction and Aggravation of Mid-esophageal Ulcers by Endoscopic Biopsy—Report of a Case—

Abstract: A 33-year-old male was admitted to our hospital with a seven months history of retrosternal pain and odynophagia. On admission the patient could take only liquid or soft diet. An endoscopic examination revealed a mid-esophageal ulcer. The ulcer was intractable. No known etiological factor of esophagitis was found. A biopsy of the ulcer exacerbated the ulcer and symptoms. Biopsies of normal-looking esophageal mucosa gave rise to new ulcers at the site of biopsy accompanied by an increase in the symptoms. While these newly formed ulcers healed within 6 weeks, it took an additional 6 months for the primary ulcer to completely disappear. The elimination of hard and hot foods, large boluses, condiments and alcohol from the patient's diet appeared to improve the condition of the ulcer and prevent recurrence. The esophageal mucosa of this patient may have an exaggerated potential to react to mechanical stimulation. Such intractable esophageal ulcers rarely appear in healthy young men and the mechanism of the abnormal reactivity of the esophageal mucosa needs to be clarified.     

Endoscopic ultrasound‐guided fine‐needle aspiration of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding: A case series

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) as a high‐risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS‐FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS‐FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS‐FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS‐FNA of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding. Larger studies are needed to confirm this finding.     

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy: A safe method for accurate diagnosis

Endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS FNAB) is a relatively new technique for obtaining specimens with excellent imaging power. The convex type of echoendoscope used with EUS FNAB provides images perpendicular to the endoscope, which differ from those of popular radial echoendoscopes and, hence, require different usage techniques. Color flow imaging is used to avoid the vessels in and around the mass during puncturing. EUS FNAB for submucosal tumors is sometimes difficult because the needle slips easily, and the gastrointestinal wall tends to be stretched when pushing the needle, which can be solved by making a dimple on the wall before puncturing. Lesions of the pancreas head, especially those at the uncus, and lymph nodes near the superior mesenteric artery are also difficult because of their distance from the endoscope and the resultant bending of the needle. Tissue sampling is more successful when the angle between the endoscope and the needle is kept at just less than 45 degrees, as this helps to transmit the hand force to the needle effectively. The complication rate of EUS FNAB is reportedly 1–2%, and so the technique is considered a safe modality, except for cystic lesions of the pancreas. Recent histological evidence is needed before applying medical therapies, such as chemoradiation and surgery, especially when imaging modalities alone cannot supply the evidence of malignancy; hence increasing importance of EUS FNAB is expected.     

Is endoscopic forceps biopsy enough for a definitive diagnosis of gastric epithelial neoplasia?

Background and Aim: Endoscopic forceps biopsy (EFB) as the primary histological diagnosis of gastric epithelial neoplasia (GEN) is debated in the era of endoscopic resection (ER). Our aim was to investigate the diagnostic reliability of EFB in patients with GEN compared with ER specimens as the reference standard for the final diagnosis in a large consecutive series. Methods: This was a cross‐sectional retrospective study at a tertiary‐referral center. A total of 354 consecutive patients with 397 GENs underwent ER (endoscopic mucosal resection or endoscopic submucosal dissection). Discrepancy rates between the histological results from EFB and ER specimens were assessed. Discrepancies that could affect patient outcome or clinical care were considered major. Results: The overall histological discrepancy rate between EFB and ER specimens was 44.5% (95% confidence interval [CI], 39.7–49.5%) among the enrolled patients. The overall discrepancy rate was significantly higher in the intraepithelial neoplasia (IEN) group than in the carcinoma group (49.8% vs 25.6%, P < 0.001). The major discrepancy rate was also significantly higher in the IEN group than in the carcinoma group (36.6% vs 7.0%, P < 0.001). In subgroup analysis of the IEN group, a major histological discrepancy rate of 33.6% (70/208) for low‐grade and 42.7% (44/103) for high‐grade IEN was found, respectively. Conclusions: Endoscopic forceps biopsy was insufficient for a definitive diagnosis and therapeutic planning in patients with GEN. ER should be considered as not only definitive treatment but also a procedure for a precise histological diagnosis for lesions initially assessed as GEN by forceps biopsy specimens.